Strategies for Readmission Reduction in Transitional Care: A Three (3) Part Process. Telehealth Alliance of Oregon Conference April 11 & 12, 2013 Jean McCormick, RN, MSN, Clinical Nurse Educator

Objectives To discuss and demonstrate the effects of the new form of handoff between OHSU providers and collaborating Skilled Nursing Facilities (SNFs). To examine the impact of the video technology surrounding the patient –alleviation of patient and family anxiety; –patient empowerment; –and most importantly, patient satisfaction. To demonstrate the cost benefit for both facilities with the emerging changes in health care.

OHSU Telehealth Activities – Across the Continuum *Other uses: Language interpretations Continuum of Care

The OHSU Telemedicine Network 15 sites covered 6 different services (stroke, pediatrics, neonatal, genetics, trauma and neurosurgery)

ED, Nursery, Acute Care Consults by Month Since May 2010: 421 emergent consults 262 Transfers to OHSU 159 remained in community (38%) Averted transport savings: >$2,202,440

SNF – OHSU Telemedicine Collaboration Goals –Reduce Readmissions –Reducing the per Capita costs of Care for Populations; –Improving the Health of Populations; and –Improve the Individual Experience of Care

The Three Part Process… Nurse to Nurse “Warm” Handoff Brown Bag Educational Sessions Coming Soon: MD Video Connections

Nurse to Nurse Video Handoff

Nurse to Nurse “Warm” Handoff What is a “warm” handoff? EMR Documentation Workflows Benefits and Challenges Goals

EMR Documentation

Workflows are Key..

Benefits Quality Review Creating a Visual Care Plan Builds rapport between providers at collaborating facilities Patients –Alleviates anxiety for patient/family –Empowers patients in their own care – “15 minutes of fame”

Technology Buy – In Constant Work in Progress (changes in dynamics, teaching, workflow, and turnover) Quality Review – the good, the bad, and the ugly.

SNF Educational Brown Bag Series Education – the 2 nd Part of the Process Monthly topics chosen based on identified needs Enabled through our health system video bridge Up to 40 endpoints can connect

SNF Educational Sessions—Lessons Learned Quality Reviews Teaching on the Bridge… Technology Challenges Presentations (Evidence based practice, simulation, and collaboration) Outcome of 1 st Quarterly PICC/ID Series Goals and Future (CMEs, more simulation and real time interaction, and more sites)

Continuous Work towards Lowering Readmissions – SNF Consults… Third & maybe not Final Part of Process.. Review of Skilled Nursing Facility Patient Re- Admissions Reasons Hospital Department/Physicians/Medical Directors at SNF Buy-In No Credentialing Possible Challenges Ahead

SNF Consult

Conclusion & Summary Tying it all together… the 3 part process Electronic medical records Know your institution Process Flow (from billing, credentialing, activation, documentation, to having a contingency plan) Buy-In -Workflows -Education & Handouts -CNO, Nurse Managers, Nurse Units -Staff Meetings Technology is your friend!

Presentation Takeaways Understand the effect of utilizing video technology to communicate a discharge report (e.g., pros, cons, problems, benefits, and future projects). Recognition that telemedicine can be a valuable tool for all care transitions, including discharge from the hospital to a skilled nursing facility, in line with the Triple Aim. Recognition that telemedicine is an effective tool to empower patients and to establish rapport between health care providers.

Acknowledgement and Thank You!!! Miles Ellenby, MD, Medical Director of Telehealth Services Mark Lovgen, Director of Telehealth Services Danielle Willard, Project Coordinator Kristoffer Kelly-Campanale, IT Engineer Nancy Trumbo, Director of Care Management and OHSU’s Care Management team Floor Nurses and partnered SNFs

Questions?